BACKGROUND:
On October 18, 2003, the Pennsylvania Department of Health (PA DOH), Division of Immunizations was notified of a suspected case of respiratory diphtheria in a 63 year old man after a white membranous exudate was visualized during a tracheotomy. From October 3-10, this man and seven other men from New York, Pennsylvania and West Virginia traveled to a rural area in Haiti. The previously healthy Pennsylvania resident reported never being vaccinated against diphtheria.

OBJECTIVE:
Obtain diphtheria anti-toxin, notify the Centers for Disease Control and Prevention, determine contacts and susceptibility, and contact the New York and West Virginia Department of Health.

METHOD:
The PA DOH Bureau of Epidemiology notified CDC on October 18, 2003 and diphtheria anti-toxin (DAT) was obtained and administered the same day. Contact investigations identified seven traveling companions, several healthcare providers, two people in New York State with whom he spent the night upon returning to the states and his wife. All received erythromycin prophylaxis, were monitored for seven days for the development of symptoms, had nasophyaryngeal swabs obtained for culture and PCR, and received a diphtheria containing vaccine if incompletely vaccinated or it had been >5 years since their last dose.

RESULT:
Case tested PCR positive for C. diphtheriae tox genes and died October 20, 2003. All contacts cultures and PCR results were negative for diphtheria.

CONCLUSION:
A copy of the autopsy report, death certificate, medical records and charts and all completed documents that accompanied the DAT must be sent to the Internal Review Board at the CDC.

LEARNING OBJECTIVES:
All travelers, regardless of age or destination, should ensure they are up-to-date on all routine immunizations including a primary series of diphtheria toxoid containing vaccine including a dose within the last 10 years.